Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Hi Dr. Sher
I know you are very busy but can you take one minute out please? I would so greatly appreciate it. According to your article (https://www.drgeoffreysherivf.com/pgs-in-ivf-are-some-chromosomally-abnormal-embryos-capable-of-resulting-in-normal-babies-and-being-wrongly-discarded/ ) do you think I should transfer the(Monosomy 15, Trisomy 16) back in?
I highlighted in red to make it very easy to read. Here is my grade below inred (below it explained in quick sentence with the number means). Can you please tell me if I should transfer this one in redback in? (I think the other two are no good.)
40729-4: Day 5 completely hatched blastocyst, grade 633. (complex abnormal)
70729-7: Day 6 blastocyst, grade 333 (complex abnormal)
50227-1: Day 6 hatching blastocyst, grade 523 (Monosomy 15, Trisomy 16)
OOCYTE AND EMBRYO GRADING
A) The first number corresponds to the progression of the blastocyst (1-6). A higher number corresponds to a more advanced stage in blastocyst development. Blastocyst
1.Early blastocyst (blastocoel cavity original volume of the embryo, zona is thinned) (EXBL)
5.Hatching blastocyst (trophectoderm has started to protrude through the zona )(HBL)
6.Completely hatched blastocyst (blastocyst has completely escaped from the zona ) (CHBL)
B) The second number corresponds to the quality of the ICM (inner cell mass) (1= best quality)
1.Many cells, forming a cohesive layer
2.Few cells, forming a loose layer
3.Very few large cells
C) The third number corresponds to the quality of the trophectoderm (1= best quality)
1.Many cells, tightly packed
2.Several cells, loosely packed
3.Very few cells
Thank you very much!
Kerry
Let me again say that I would recommend against transferring. In my opinion, blastocysts with single chromosomal aneuploidies are in about 30% of cases likely to be mosaic and worthy of transfer, those with more than a single abnormality are in my opinion unlikely to be mosaic. Thus I only would transfer the former and not the latter.
Geoff Sher
Hi Dr. Sher,
I had a 6 day PGS normal blast transfer done on Sept 14th. They brought me in day 8 (which they did say was a day earlier than usual). My HCG was 30.2. On day 10 my HCG was 86.6. Day 12 the HCG is 226 and the nurse said I was 4 weeks 3 days pregnant. The nurse seemed very happy with these numbers and said no reason to retest. My first scan is Monday October 9th. (I will be 6 weeks 2 days at that point). I guess I am just nervous because I would of loved to see a very high number. Normal numbers seem to vary. But I am still very nervous. I have ZERO symptoms besides sore breasts. But that isn’t even bad. I did have a headache for 3 days. But that disappeared 4 days ago as well. Is that something to be worried about? I do want to thank you in advance. You are very helpful to a lot of people. I enjoy reading your blog!
Thank you, Karina
Can someone like me with PCOS be able to have a baby? I have been through 2 failed egg retrievals. The 1st attempt had my follicles disappear. The 2nd attempt, eggs could not be found in the follicles. What should I do?
Let me start by saying that there is no doubt that PCOS exacts a toll on egg quality. This having been said, the egg quality can in large part protected through the judicious implementation of an individualized protocol for ovarian stimulation.
Women with PCOS are hypersensitive to gonadotropin stimulation and are often at risk of developing serious complications associated with severe ovarian hyperstimulation syndrome (OHSS). Concern for this occurring often leads the treating physician to take precautionary measures aimed at slowing down or stopping hyperstimulation. Such measures include:
1. Cutting the stimulation short to prevent the E2 from rising too high. Unfortunately this often results in the eggs being underdeveloped at the time of the “trigger” and thus, far more likely to end up being “immature”., “dysmature” and “incompetent”.
2. Administering a lower “trigger dosage” of hCG , supplanting it (partially or completely) with an Agonist trigger (e.g. Lupron/Buserelin/aminopeptidyl/Superfact). While such measures can certainly reduce the risk/severity of OHSS, it often comes at the expense of egg competency (see below).
In my opinion, another error of commission during ovarian stimulation of women with PCOS is the indiscriminate use of drugs that either elicit an exaggerated ovarian LH-induced testosterone response (e.g. clomiphene or Letrozole), or provide too much LH (e.g. Menopur/Menogon). Too much ovarian testosterone is harmful to egg development and thus prejudicial to embryo quality/competency.
In my opinion the best way to approach ovarian stimulation for IVF in women with PCOS, is through the use of a low dosage, FSH-dominant Long ovarian down-regulation protocol, done in readiness for “prolonged coasting” (see below) and “triggering” egg maturation with a full 10,00U dosage of hCG or (no less than) 500mcg of recombinant hCG (Ovidrel)….see below is If this is implemented appropriately, with proper timing, egg/embryo quality can be optimized.
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The Fundamental Requirements For Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
•Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Taking A Fresh Look at Ovarian Hyperstimulation Syndrome (OHSS), its Presentation, Prevention and Management
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
•“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
•The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
•My Retirement in the Year Ahead: A letter of Thanks From me to You!
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
After 12 days on puregon and menopur with Saizen every other day I was instructed to inject pregnyl tonight at 9:30pm and Lupron at 10:30pm. However i fell asleep waiting and didn’t wake to inject until 10:00 pm; 30 mins late on Pregnyl and took Lupron on time. What are the implications of this?
I don’t think 30mn will make a difference…but inform your RE tomorrow.
Geoff Sher
According to your article (https://www.drgeoffreysherivf.com/pgs-in-ivf-are-some-chromosomally-abnormal-embryos-capable-of-resulting-in-normal-babies-and-being-wrongly-discarded/ ) do you think I should transfer the (Monosomy 15, Trisomy 16) back in?
If it helps I got a grade of 523 (see the corresponding **):
OOCYTE AND EMBRYO GRADING
A) The first number corresponds to the progression of the blastocyst (1-6). A higher number corresponds to a more advanced stage in blastocyst development. Blastocyst
1.Early blastocyst (blastocoel cavity original volume of the embryo, zona is thinned) (EXBL)
**5.Hatching blastocyst (trophectoderm has started to protrude through the zona )(HBL)
6.Completely hatched blastocyst (blastocyst has completely escaped from the zona ) (CHBL)
B) The second number corresponds to the quality of the ICM (inner cell mass) (1= best quality)
1.Many cells, forming a cohesive layer
**2.Few cells, forming a loose layer
3.Very few large cells
C) The third number corresponds to the quality of the trophectoderm (1= best quality)
1.Many cells, tightly packed
2.Several cells, loosely packed
**3.Very few cells
Thank you very much!
Kerry
In my practice I would be very reluctant to transfer an embryo with > a single chromosomal defect.
Geoff Sher
I have done 3 IVFs so far. My first I had 3 ER and 3 fertilizing but all 3 did not make it past day 3. My second IVF cycle immediately following (5 days of clomid then 450 Follistem and 40 low dose HCG) resulted in 5 eggs all mature but 3 fertilized with ICSI and frozen on day 1 to bank. I just had my 3rd IVF today same protocol as 2nd and only had 3 Eggs retrieved but all 3 were NOT mature. I am starting to lose hope. I am 39, almost 40 in Dec. I have 2 children from previous marriage 15 and 12 that I conceived naturally. My husbands sperm isn’t the greatest which is why we are doing ICSI, his could has been 500,000 on the 1st IVF and 800,000 on the 2nd. I don’t know third bec we never made it to fertilization. I don’t know if my RE will go through with the frozen transfer with the 3 we have frozen but do you think I should continue or look at donor. I don’t know how much emotionally i Can take? Do you think other medications might work better? What is the normal amount of follicles per cycle for a 39 year old. my AMG was .28.
WE should talk! Please call Julie at 800-780-7437 and set this up.
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
•The Fundamental Requirements for Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Blastocyst Embryo Transfers should be the Standard of Care in IVF
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF?
•The Role of Nutritional Supplements in Preparing for IVF
•Male Factor Infertility
•Routine Fertilization by Intracytoplasmic Sperm Injection (ICSI): An Argument in Favor
•Hormonal Treatment of Male Infertility
•Hormonal Treatment of Male Infertility
•Antisperm Antibodies, Infertility and the Role of IVF with Intracytoplasmic Sperm Injection (ICSI)
•Testicular Sperm Extraction (TESE) and Testicular Sperm Aspiration (TESA): Surgical Approaches for Accessing Sperm from men who have no sperm in their ejaculates (Azoospermia)
•Varicocele and Male Infertility: When and how should it be treated?
•The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD